Healthcare Provider Details

I. General information

NPI: 1467989483
Provider Name (Legal Business Name): TRAVIS PATRICK LYMAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BRYSON DR
SUTTER CREEK CA
95685-4118
US

IV. Provider business mailing address

10 BRYSON DR
SUTTER CREEK CA
95685-4118
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-1402
  • Fax:
Mailing address:
  • Phone: 209-223-1402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33760TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: